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Breast Study

Confidential Questionnaire

Birthday
Month
Day
Year

All information given in the questionnaire will remain strictly confidential and will only be divulged to the reporting thermographer and any other practitioner that you specify.

1.) Have you recently had any of these breast symptoms?
No
Yes

If yes please check any of the boxes below:

Pain/Tenderness
Lumps
Change in breast size
Areas of skin changing, thickening or dimpling
2.) Are any of the above symptoms cycle related?
No
Yes
3.) Are you still having periods? If yes, date of last period
No
Yes
4.) Have you had a surgical hysterectomy?
No
Yes
If yes, was it a complete of partial?
Reason for hysterectomy
5.) Has anyone in your family ever been treated for breast cancer?
If yes:
6.) Have you ever been diagnosed with breast cancer?
No
Yes
Cancer Type
Left Breast:
Right Breast
Treatment:
If Surgery:
7.) Have you ever been diagnosed with any other breast disease?
No
Yes
If yes:
8.) Have you had any cosmetic breast surgery or implants?
No
Yes
Type:
Experience:
9.) Have you ever had any biopsies or any other surgeries to your breasts?
No
Yes
Left Breast:
Right Breast
Results:
10.) Have you ever taken contraceptive pills for more than one year?
No
Yes
If yes:
11.) Have you had pharmaceutical hormone replacement therapy (HRT)?
No
Yes
If yes:
12.) Do you have an annual physical examination by a doctor?
No
Yes
13.) Do you perform a monthly breast self-exam?
No
Yes
14). Have you ever smoked?
No
Yes
15.) Have you ever been diagnosed with diabetes?
No
Yes
16.) Have you had a mammogram?
No
Yes
Were you re-called?
No
Yes
19.) Number of full-term pregnancies?
20.) Have you had a breast ultrasound?
No
Yes
If Yes:
Results
21.) Have you had a breast MRI?
No
Yes
If Yes:
Results
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